HomeMy WebLinkAboutSUBMITTED PAPERSFee Due: DcS
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of
❑ Electrical
❑ Shed
Planning & Development Services
Building & Code Regulations Division
2300 Virginia Ave. SCAfNNE�,
Fort Pierce, FL 34982 BY
(772)462-1553 St L_UCi@
CoUrrfy,
SPECIALTY PERMIT APPLICATION
Plumbing ❑ OVAC ❑ Fence
Demolition ❑ ;Gas ❑ Siding
Seepage 2 for instructions and additional paperwork required for specialty permits
1. Location/Site Address: l QZ. NC-U (c5 g(, d
2. Parcel ID Number: t}rjQ'Z.' SG 1- 8;6-7$ - 600 ^ l
Township
Range
Map Page
Zoning
Land Use
Initials
(.1%/'ire [rsc>
Section
Only
3. (
4. Owners Information 1 5. Contractors Information
Name: A bt4 4- E 64bA trc%c v'
Address: I V4 qM-5QC(4 a \le .
City: Plasm Min State: N l
Zip: ('LQ Q Phone:
6. Value of Construction: $ (%
FL Reg/Cert #: OtA'A Q
County Cert#:
Business Name:
Phone:-112-299-4q &Q Fax: 1i*2- 27A - Qq(/Q
OWNER'S AFFIDAVIT: 1 certify that all of the information contained in this application is correct and that all work will be done in
compliance with all applicable laws regulating construction and zoning.
PRINT OWNER OR CONTRACTOR NAME SIGNATURE OF OWNER OR CONTRACTOR
STATE OF FLORIDA, COUNTY OF-� 0--�
ACKNOWLEDGED BEFORE ME THIS
DAY OF 20 13 , BY
WHO IS PERSONALLY KNOWN TO ME OR WHO HAS PRODUCED
AS drQ N.
DAVID N. KNEPPER
f M} QpQ �� orb ��� �� =_•; k: Commission #, Dq 995518
SIGNATURE OF NOTARY TYPE OR PRINT NAMI; OF N '1 ARY Expires Sept e �25, 2014
h,p, � Bonded ThruTmyFaiaInsurance 800385.7018
COMMISSION NUMBER
NOTICE TO OWNER: FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR
IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TC OBTAIN FINANCING, CONSULT WITH YOUR
LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT.
EXEMPT: A/C -HEAT REPLACEMENT WITH CONTRACT UNDER $7500.00
Revised 04/26/2010
ASBESTOS NOTICE
Asbestos Notice to Contractor
September 09, 2013
MEL-RY CONSTRUCTION
MACK MATOS
10967 S OCEAN DR
JENSEN BEACH, FL 34957
RE: Building Permit Number 1309-0090
It is your responsibility to comply with the provisions of Section 469.003, Florida Statutes and to notify the Department
of Environmental Protection of any intentions to remove asbestos when applicable in accordance with state and federal
law.
Signature
? q ij
Date
9/9/2013 2:30:56 PM